Provider Demographics
NPI:1578902235
Name:PANTALENA, LUIZ FERNANDO (DMD, PHD)
Entity Type:Individual
Prefix:DR
First Name:LUIZ
Middle Name:FERNANDO
Last Name:PANTALENA
Suffix:
Gender:M
Credentials:DMD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2245 W. COLUMBIA AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015
Mailing Address - Country:US
Mailing Address - Phone:269-964-7660
Mailing Address - Fax:269-964-4041
Practice Address - Street 1:2245 W. COLUMBIA AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015
Practice Address - Country:US
Practice Address - Phone:269-964-7660
Practice Address - Fax:269-964-4041
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901021007122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist